HomeMy WebLinkAbout038-1196-50-000 Wisconsin Depattment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399466 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Permit Holder's Name: City Village X Township Parcel Tax No:
Blietz, Brian I Star Prairie Township 038 - 1196 -50 -000
CST BM Elev: Insp. BM Elev: BM Description:
(0 d
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic l a�tJ Benchmark
S LJ rZZ 0 -z 0
Dosing Alt. BM
Bldg. Sewer
Aeratio 2 U•
Holding tot Inlet A
St/ t Outlet q O r�
TANK SETBACK INFORMATION 1 6
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic 7 i J
Header /Man.
Dist. Pipe L 9
Aeration -T - ZS
Q t �-
ding
Bot. System L Q • y 82 . YS
f_ 0
Final Grade k
PUMP /SIPHON INFORMATION
Ma ufacturer Demand St Cover A
GPM
Model Number � V 0, 3
//.
TDH Lift Friction Loss tem Head TDH
Forcemain Length Dia. Dist. to
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches rTIMENSIONS No. Of Pits Inside Dia. Liquid Depth ' 1 DIMENSIONS 3 T Z
SETBACK SYSTEM TO P/L JBLDG WELL LAKE/STREAM LEACHING Manufactu r.
INFORMATION H BE OR O
Type Of System: S / -/ M 1 Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
�/ 0
Pipe(s) /� f l,/ ,
�
(� ( Dia Sp acin r Length .s Dia 9
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of ] rx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes [it No rim� Yes [W No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:!$/ d Inspection #2:
Location: 2161 132nd Street New Richmond, WI 54017 (Unknown 13 T31N R18W) Pine Acres Lot /� / Parcel No: 13.31.18.1029
1.) Alt BM Description = BT 'T p too / /
�
2.) Bldg sewer length
- ff amount of cover = > 3 / S% hnaGYjGt .
�,BpsCvVCcTA.— . of A-6 411e 4-
Z (1 � �� d—
Plan revision equired? Yes No R 7- /
Use other side for additional information. l e
Date Insepctor's nat re Cart. No.
SBD -6710 (R.3197)
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Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
14 sconsin Personal information ma ou provide be used for second u Madison, WI 53707 -7302
Department of Commerce y p y purposes (Submit completed form to county if not
[Privacy Law, s. 15.04(1)(m)] state owned.)
Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size.
County State Sani Permit Number 11 Check if revision to previous application State Plan I. D. Number
s.� 3 ?I y
I. Application Info - Please Print all Information Location:
Property Owner Name Property Location
/ I 0..e � t / / � /iILA1 S 1/4, S �I � �N, R � (o (W)
Property Owner's Mailing Address LZ Lot Number Block Numb
s 3
City, State Zip Code . Number Subdivision Name or CSM Number
II. Type of Building: (check one) t -, ;' LL ❑city
or 2 Family Dwelling - No. of Bedrooms : ; " ❑Village
• Public /Commercial (describe use):_ a* per P (ew s -j !, - OTown of
• State -Owned ST C44DA�
1 �� 0 /_ 7' Liz, r
Nearest Road
�L r 4 /
Parcel T N mber(s I
III. Type of Permit: (Check only one box on line A. Check box o i 'a able)
A) 1. 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existin System
$) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV Type of POWT System: (Check all that apply)
- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate Gals. /day /sq. ft.) (Min. /inch) Elevation
X> 3 t <3j
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersigned, assume responsibility for instal tion of the POWTS shown on the attached plans.
Plumber's Name (print) Plumber' i r (no stamps): MP/MPRS No. Business Phone Number /
Plumber's Address (Street, City, State, Zip C e)
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin gent (No stamps)
Approved 11 Owner Given Initial Adverse Surcharge Fee) /
Determination ZZ pp Z C
X. Conditions of Approval /Reasons for Disapproval:
1. Effluent filter to be installed and maintained per manufacturer's recommendations.
2. Chamber louver shall be installed in soils with a soil application rate of .7.
3. Any filling and grading that will affect the capacity of the Drainage and Ponding area is prohibited.
SBD -6398 (R. 07/00)
OT PLAN
PROJECT Brian Blietz ADDRESS 537 Svcamore Drive New Richmond Wi 54017
NW 1/4 S 1/4S 13 /T 31 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 9 BEDROOM 3
CONVENTIONAL XXX IN -GRO ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE 1.2 ABSORPTION AREA 377 # of chambers 22
BENCHMARK V.R.P. Top of 2" Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H. R. P Same as Benchmark
SYSTEM ELEVATION 78.8
j
Sidewinder High
Capacity Leaching Plans Designed Using
Chamber Conventional Powts
Manual Version 2.0
�
Grade at System Elevation 34
Pro 3 ct
Bedroom
House
10'
ST
B - 10'
5' -2
30'
2-3'X 69'
7% ��� Cells with > 3'
Slope Spacing
0
B-
B -1
25'
0' B.M.
Vents
140'
132nd ST.
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of .3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 8'h x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D.#
APPLICANT INFORMATION - Plea ► t`AWhiflirs wqn. Pendln
Personal information you provide may be used for ridarypurpor (Privacy Lake, 9,, 15.04 (1) (m)). R wed y Date
F y Owner 9 ; `i Pro perty Location
s & Hills Develo meaty `' Govt Lot 114 NW 1 14,S _ 13 T 31 ,N,R 18 n J
Owner's Mailing Address -- I 1 Lot # Block # Subd. Name or CSM#
3 // 6 �4 ,~ 34 ❑ - -- Pine Acres
City ? State $ip Code Ph6noNgi Dber City ❑ e IlTown Nearest Road
,
�� �ee� :� '� /G r i''8 f�� ; L 132 Nd ST.
❑ New Construction Use: ❑ Re`siidential / Number of be 3 ❑Addition to existing building - --
❑ Replacement ❑ Public 6r commercial d6s'cribe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/f 2 8 trench, gpd/ftz
Absorption area required 643 bed, fF 562 trench, it" Maximum design loading rate .7 bed, gpolftz .8 tr ench, gpdff
Recommended infiltration surface elevation(s) 80.1 ft (as referred to site plan benchmark)
Additional design / site considerations Alternate Area Elev. 78.8
Parent material - - - - -- Flood plain elevation, if applicable - --- -- ft
S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system ®S ❑ U ® S u ❑ S❑ U ® S❑ U ❑ S® u ❑ S z U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ftz `� w
Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench (�(�
1 1 0 -12 10YR3 /3 ------------ - - - - -- 1 lmsbk mvfr as 2f .4 5
2 12 -24 10YR4 /3 ------------ - - - - -- I lmsbk mvfr gw lvf .4 .5
Ground 3 24 -41 10Y ---- - - - - -- -- - - - - - -
cl lmsbk mvfr as - - -- 2 3 Z
elev
83.7 ft. 4 41 -67 7.5 ----- - - - - -- cs osg ml gw - - -- .7 .8
5 67 -99 7.5YR4/6 ----------- - - - - -- s osg ml - - -- - - -- .7 .8
Depth to -- - - -- - -- __ --
limiting
factor
` >99"
Remarks: _
2 1 0 -10 10YR3 /3 ------------ - - - - -- I lmsbk mvfr as 2f .4 .5
2 10 -25 10YR4 /3 ------ - - - - - - 1 lms bk mvfr gw lvf .4 .5
Ground 3 25 -44 10YR4 /4 ------------ - - - - -- Cl lmsbk mvfr as - - -- 2 3 2
elev - _
84.9 ft. 4 44 -69 7.5YR4/4 ------------ - - - - -- s osg ml cw - - -- .7 .8 �
Depth to
5 69 - 99 7.5YR4/6 ------------ - - - - -- s osg ml - - -- - - -- .7 .8
limiting
factor
>99"
Remarks:
CST Name (Please Print) Signature: Telephone No.
Jacque Hawkins L,,,,_. Y7 — � y 1/ rr
Address Date CST Number Ref #
60 (,�u w I T Y 8,T, 4/10/00 -L-, 407
PROPERTY OWNER: Lakes & Hills Development SOIL DESCRIPTION REPORT Page 2 of -3
PARCEL LD.# Pending
Depth Dominant Color Mottles Structure GPDlftz
Horizon in. Munsell Qu. 5z. Cont Color Texture Gr. Sz. Sh. � o nsistence Boundary Roots he u>
Bed Trench
3 1 0 -11 10YR3/3 ------ ------ - - - - -- I lmsbk mvfr as 2f 4 .5
2 11 -24 10YR4/3 ----------- - - - - -- I 1 msbk mvfr gw lvf .4 5
Ground
elev 3 24 -33 10YR4 /4 ----------- - - - - -- Cl lmsbk mfr as - - -- .2 .3 ,Z
83-1 ft. 4 �3 -68 7.5YR4/4 ------------ - - - - -- osg ml cw - - -- .7 .8
Depth to 5 68 -97 7.5 4/6 - - -- s osg ml - - -- - .7
limiting z w - - - -- - -- -- -- - -- 8
factor
,4 Wl , s
Remarks:
4 1 - 0 -12 1 OYR3I3 ------------ - - - - -- 1 1 msbk mvfr as if .4 .5 .
2 - 12 -26 10YR3 /2 ------------ - - - - -- 1 lmsbk mvfr gw lvf .4 .5
Ground
3 26 -45 10YR4/4 Cl lmsbk mfr as - - -- .2 .3 z
e l ev ------------------
83.4 ft. 4 -67 7.5YR4/4 ------------ - - - - -- c�jD osg ml gw - - -- .7 .8
Depth to 5 67 -95 10YR5 /6 �s j osg ml - - -- .7 .8
------------ - - - - -- - - -- -
limiting —
factor aj W P, �
>95"
Remarks:
5 1 - 0 -9 10 YR3 /3 ------------ - - - - -- 1 lmsbk mvfr as 2f .4 .5 `J
2 9 -15 10YR4/3 ------------ - - - - -- 1 Imsbk mvfr gw lvf .4 .5
Ground -- — 2
3 15 -32 10YR4/4 --- - - - - -- Cl lmsbk mfr as 2 3
elev - - --
81.7 ft. '
2 -75 7.SYR4/4 - -� osg ml
4 ---------- - - - - -- - - --
- - -- 7 .8
Depth to
limiting
factor
>75"
Remarks: - - -- -- - - -- -- - -- -- — - -- - - - - --
Ground —
elev _
ft.
Depth to
limiting -- -- —
factor
Remarks:
� o
2 q
� � w
f rJ
--,Iz; \ �.
3 h
I,
h
�— —co
a
o
Wisconsin Department of Commerce VALUATION REPORT Page of
Division of Safety and Buildings t '
in ae n $omm 85, W.is dm. Code
` County
Attach complete site plan on paper not less t{��1es* size. Pljn4wst
include, but not limited to: vertical and horizo 'd'l� ectiori and Parcel I.D.
percent slope, scale or dimensions, north arr and dfcto nearest road.
Please print al rm iill7�n. 9n n Re ' wed by Date
Personal information you provide may be used for ec dary purp �ecy L Y8/, s. 15:04,(1) (m)). Z
Property Owner ,' ( Prope y Location
` �� ' Govt. Lot /✓k; 1145 1/4 V3 T3 N R E (o
Property Owner's Mailing Addre s �,, tot # Block # Subd. Name or CSM#
S.3 7 G'a.��r� ?q - 9 I C4
City State Zip qbde Phone Number ❑ City ❑ Village .Town Nearest Road
) pr
w Construction Us esidential / Number of bedrooms Code derived design flow rate -S O GPD
❑ Replacement ❑ Public r commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments
and recommendations:
���
❑ Boring
Boring #
Pit Ground surface elev. 3' ft. Depth to limiting factor in. rE-Eff#1 Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#2
F—I Boring # F1 Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 1 m ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
CST Name (Plea a Print) ` a re CST Number
Address at Evaluation Conducted Telephone Number
/
SBD -8330 (R07 /00)
Property Owner Parcel ID # Page of
❑ Boring #
❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz.'Sh. *Eff#1 *Eff#2
F] Boring #
E] Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00)
Ln7 TAN
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Pro : 'ty
°r
(Verifica: ion requirr -d from Planning Department for new construction
Iarccl Identification Number ,� ✓ / U�
I.,:1?G J , D1 8 ; UI'TI4r'A
5 ` /,, Sec. j'.�I._...iV / 1�', 'I vti�rn ui s17i �...d'��. ✓I1 rf
Su d v I51tJIt
+C'ery led St: :x,a y Mu.p ;q ..:��. _. _ � .,_..._ � "c�Iurrry `' -'age # _
Volume
Spec; louse 111s Pn,o Lot lines identifiable tS,yes (::j no
Impro rx- i:a.e and maivten,anceof your septic system could result in its premature failure to handle wastes. Properma�uien:ance
consiv ; of pux tpir zout the sel.Aic: tame every three yem or sooner, if needed by a iicensed pumper. What you pur" into ttse. system
can. af:t..et the ritrr:.rtan of the septic tank as a treatment stage in the waste disposal systerra
The p.cd?i:, ^ry owner at;xees to subs ut to St. Croix Zoning Depmtment a certification form, signed by the,owner,; by a
waster plumbs--, j rn::tneymwpltkmbai, rtstdctedpluuiber or a licensed pumper vcx ifying that (l ) the vv -site Wastewate;td aptis"ji :system
is in P - )per opir'eit ,: qg condition and/or (2) after inspection and pumping (if necessary)., the septic tank is lass than 113 full of- sludge"
Uwe, :. ie undci:si ?r;,i:d have reac the above, requirements and agree to maintain the private sewage disposal system with thrr• {;tsadards
set fcj. a , set by the Veparanent of Couunerce and the Department of Natural Resources; State of Wisconsim Cei'�tiration
statiri.tr. rthat YOU ;;:`; rtic system f as been maintained ,must be completed and returned to the St, C roix County Zoning, Office ,- l4i hin 30
stays o thc. tb:�- - r •, , _it expiratiiT; elate.
a6ax. � �'ra
DA YE
FYI C
I (we):coxi.ify that all , on this form are true to the best of my (our) knowledge. I (we) am (arc) the ow'aor(s) of
the pz^::5erty dt'sc. ri'i izd above, E; y virtun of a warranty deed recorded in Register o Deeds Office
d
A / JJ
PIPI -; A r�A 1I
�• *''' Any infii ideation that i<c nus- represented may result in the sanitary perrn.it being revoked by the Zoning 7: 7epartarseu'•:: " * *"*
* Inn:,ude withal, is applicati.�in: a stamped warranty deed frog the Register of Deeds oifice
a copy of the certified stuvey map if reference is made ?'11 the wertg.nr deed
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed Is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
0 201a--y
Shaun Bird #226900
v ,I 1722
STATE BAR OF WISCONSIN FORM 2 - 1999 6571.1 7
WARRANTY DEED X i 1LEEN H. WALSH
Document Number REGISTER OF DEEDS
sf. . Cr:_i.lx Co., WI
This Deed, made between Lak and Hill Inc., a M innesota RECEIVED FOR RECORD
Corporation, -
- - -- AM
_- - -.. -_ iit!:iRANTY DEED
Grantor, and Bria R. Blietz and Meagan M. Ca mpeau 4
TnANSFEA FEE: 83.70
_- REC�RD:`NG FEE: 11.00
N,3ES: 1
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Cr oix _ County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 34, Pine Acres, Town of Star Prairie, St. Croix County, Wisconsin. Name and Return Address
DAVID J. ESTREEN
304 LOCUST ST. -7 'L yo
HUDSON, WI 54016
•r
Pt 038- 1054 -9 -000
Parcel identification Number (PIN)
This is not _ homestead property.
OE) Us not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this l day of Septemb 200
' Lakes and Hills, Inc.
S. Nels Pr ident
M ;
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) L akes a nd Hills, Inc., by Richard S. Nelso its STATE OF WISCONSIN )
President, ) ss.
County )
authenticated this R 41 day of September 2001
Personally came before me this day of
—__- the above named
. . Kristl d a+td .....
TIT � t z .. :R S i . m _ - -- 10 1 1 - - - ,r -
lf-nu4 cVV O`�Lt P pub �r'L /fir @/4e� (, ( )Z to me known to be the person(s) who executed the foregoing
—c- - instrument and acknowledged the same.
tRhorizf8 by § 706 06, Wis. Stars.)e , �a
TH1S"1NSSTRUMENT WAS DRAFTED BY
Attor i ;3ti O I`a ud
Hudson, 6181 " —. Notary Public, State of Wisconsin
— My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) ___... -__ -_. ,
Names of persons signing in any capacity must be typed or printed below their signature. 1nlormat— P.otessonais comvany. Fora du Lac, vn
WARRANTY DEED
STATE BAR OF WISCONSIN 800-655 -2021
FORM No. 2 - 1999
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